These comments are responses
to the questions listed below,
which were generated in regard to the Sanne Magnan
Interview of 10-01-10..

The Questions:

Minnesota Dept. of
Health Commissioner Sanne Magnan says we're spending too much on
health care and receiving too little in return. Unless changes occur,
spending on health care in Minnesota will double in the next eight
years. New measurements will soon make it possible to compare health
care providers based on quality and cost. Consumers should be given
incentives to choose value-based health insurance. Physicians and
other providers should be held accountable for outcomes and cost. For
the complete interview summary see:
http://bit.ly/aGOlOe

Response Summary:
Readers have been asked to rate, on a scale of (0) most disagreement,
to (5) neutral, to (10) most agreement, the following points discussed
by Commissioner Magnan. Average response
ratings shown below are simply the mean of all readersí zero-to-ten
responses to the ideas proposed and should not be considered an
accurate reflection of a scientifically structured poll.

1. Health care
assumptions
(8.8 average response) It is not
necessarily true that more service or more expenses assure better
health care.

2. Comparing
quality and cost
(6.2 average response) A new developing
system enabling consumers to compare quality and cost of different
providers will significantly help Minnesota
restrain its rapidly escalating health care expenses.

3. Incentives to
consumers
(7.3 average response) State and local
government and private health plans should offer incentives for
consumers to choose providers based on cost and quality.

4. Accountability
(7.5 average response) Physicians and
other providers should be held accountable for outcomes and cost,
instead of only being paid for patient visits, tests, procedures and
hospitalizations.

5. Specialists
(7.1 average response) Relatively less
compensation should be given to specialists and relatively more to
primary care physicians.

Response
Distribution:

Agree Strongly

Agree
Moderately

Neutral

Disagree
Moderately

Disagree
Strongly

Total
Responses

1. Health care
assumptions

6%

0%

0%

33%

61%

18

2. Comparing
quality and cost

6%

22%

17%

33%

22%

18

3. Incentives
to consumers

11%

6%

11%

33%

39%

18

4.
Accountability

11%

6%

0%

44%

39%

18

5. Specialists

11%

17%

6%

17%

50%

18

Individual
Responses:

Ray Ayote (10) (7.5) (10) (10) (10)

Polly Bergerson (10) (5) (5) (10) (10)

W.D. (Bill)
Hamm
(10) (2.5) (0) (7.5) (2.5)

1.
Health care assumptions. Depends on your definition of "health care".
Like most folks in the bottom 62% (not rich or middle class), we are
looking for a system that is: (1) designed to be in my best interest
first and foremost, (2) designed to protect from tort and encourage
personal improvement in the professionals within our medical system.
(3) (would) give none of my money to either insurance companies or new
governmental bureaucracies. None of the proposals and schemes so far
put in our faces by these arrogant elitist politicians comes even
close to these three simple objectives.

2.
Comparing quality and cost. This nonsense does nothing to, first,
help improve or police doctor or professional ranks; second, such
figures will favor doctors who are smart enough to cherry pick which
patients they take, forcing other doctors to take on riskier patients
thus skewing the figures.

3.
Incentives to consumers. Quality health care, from the patient point
of view, should be what is driving the system, not profit, not what
protects the institution. Your ridiculous incentives do nothing to
change the way the existing system thinks of us, as the person
receiving health care rather than the allocation of resources.

4.
Accountability. The whole system should be built around patient
driven outcomes defined by patients. Then and only then can doctors
and professionals as well as processes be evaluated from the proper
perspective.

Robert Freeman (10) (7.5) (10) (10) (10)

1.
Health care assumptions. Study after study has proved this to be the
case. However our system provides an incentive to do more, not less.
Imagine what contracts would look like if we paid lawyers by the
word. That is the system we have for health care.

2.
Comparing quality and cost. If implemented correctly. We also need
to reform the way in which we pay for health care. Since the
government pays for about half of medical care, it needs to lead by
example.

4.
Accountability. With the proviso that providers are not good at
managing risk - but they are very good at providing care.

Peter Hennessey (7.5) (2.5) (7.5) (0) (2.5)

1.
Health care assumptions. This is true; it depends on external
factors: (1) how sick the patient is, (2) how willing the patient is
to follow his doctor's instructions. (3) how up-to-date the doctor is,
(4) how much time the doctor has to spend with the patient to get all
the facts and form the correct diagnosis, then explain all the details
and treatment options to the patient, at the patientís level of
understanding. There is nothing the third party payer can do about
(1) or (2), licensing bodies take care of (3), and third party payers
with their decreasing reimbursements are working directly against
everybody's interests in (4).

2.
Comparing quality and cost. Short of weeding out incompetent
providers, which is a function of licensing bodies, there is nothing
the third party payers can do except tinker with the reimbursement
rates, and thereby make the problems worse. All this talk about
quality and cost is good-sounding nonsense that neither the patient
nor the third party payer can possibly define and quantify to
everyone's satisfaction. The doctor-patient relationship is unique to
each paring of a specific doctor to a specific patient, even if it
were possible to assume that every patient's illness and the course of
that illness is precisely identical. For a variety of reasons, a
specific doctor and a specific patient may assign a different degree
of severity to the patient's condition, and the patient might prefer a
different course of treatment. There is no amount of standardization
and the consequent imposition of certain treatments and the
prohibition of others that can force every patient, every illness and
every treatment into a satisfactory cost-benefit model.

3.
Incentives to consumers. Having disposed of the notion that cost and
quality are factors that a patient or even a panel of "experts" can
possibly determine with any level of authority and credibility, the
only thing left is the patient's freedom to choose his own doctor.
Sorry, but even health care is a human activity that is governed by
the rules of the free market, no matter how it is distorted by the
efforts of third party payers to standardize everything. At some point
you have to admit that the patient must be left free to choose --
choose to admit he has a problem, choose to admit that the problem is
severe enough to seek help, choose to admit that he is happy with his
doctor, choose to admit that the treatment is something he can
tolerate and follow. There is nothing that any third party payer can
do about this, except refuse to pay because the patient does not
follow the standards they seek to impose on everybody.

4.
Accountability. There is no way the doctor can be held accountable
for outcomes (with the obvious exception of criminal behavior).
Everyone does not have the same illness, to the same degree, under the
same living, exercise, nutritional and other conditions. Everyone does
not respond equally well to the same treatment. Some respond to no
known treatment. On the other hand, the doctor's effort to help the
patient takes time, and the treatment involves the use of medicines
and equipment that cost money to buy. How else will you reimburse the
doctor if not on the basis of service provided? So if the patient has
terminal cancer and dies, the doctor and hospital get nothing because
the outcome is the obvious failure to save him? If the treatment
extends your life, by how long must your life be extended in order for
the third party payer to reimburse the doctor? We all die, eventually;
is that too an outcome that the doctor is responsible for, and
therefore the third party payer will never pay him for anything? What
kind of society are you building where the doctors are turned into
slaves?

Bob White (10) (7.5) (10) (7.5) (10)

Ray Schmitz (10) (10) (10) (7.5) (10)

2.
Comparing quality and cost. I asked that my employer require on the
self-insurance plan that the cost of overhead be included in the
information provided on a claim, this was rejected as "not cost
effective". I suggest this is the kind of info that would lead to
lower cost.

Dave Broden (10) (5) (10) (7.5) (5)

1.
Health care assumptions. Agree, There is far too much focus on cost
vs. value and outcome. This is a broad problem of management thinking
not just related to health care. System thinking must be on what needs
to be done and how it should be done and then how does it get done in
the best way not how do you do something within a cost level--the
bucket will always be full if cost is the starting point.

2.
Comparing quality and cost. This is a great approach. The measure of
success will be on how it is done, implemented, and what is the
result.

3.
Incentives to consumers. The concern here is to establish measurable
metrics that are common and applied to all in the same way. This will
be the hard part.

4.
Accountability. Agree-- there may need to be a reasonable mix on this
to cover some areas but the idea must be the primary focus in the
future.

Rick Bishop (7) (7) (7) (10) (10)

Austin Chapman (8) (4) (4) (6) (8)

4.
Accountability. How does one "hold accountable" physicians and
providers for outcomes? 5. How?

Ralph Brauer (0) (0) (0) (0) (0)

I rated these all
a zero because they show a total lack of understanding of the systemic
implications of these proposals and the health care system. As a
newly released study shows a relatively small number of high-cost
patients are a problem for the system in part because the reasons for
their high costs are unpredictable--serious heart attacks, infections
that do not react to antibiotics, strokes, serious accidents. This
interview shows why you need to get off this "accountability" kick and
get some systemic understanding. The statistical premise behind all
these remarks is essentially indefensible and a great example of not
understanding systemic feedbacks. They are based on the notion that
simple linear, spreadsheet databases without feedback loops will help
define health care, but as my surgeon father used to say when asked by
patients about their chances of surviving a particular procedure,
"There are no statistics in individual cases." Health care
professionals know high-risk and high-cost cases when they see them so
this system would encourage them to pass them on to someone else for
fear that one bad result (and in a high risk field like brain surgery
that oftens means death or life in a nursing home) will skew their
performance ratings. Say I am rated on ten patients and eight of them
have good outcomes (say the systems ratings give me an average of 8
for all of them) but then I have two complex cases that cost more
money and more time and each has a less than favorable outcome earning
me a two on the ratings list. My overall score now drops from 8 to
6.4. On the other hand what if I had a choice of taking a low risk
patient over a high risk one--one that might earn me a ten. My rating
goes up to 8.4--a difference of two full points based on which
patients happen to walk in the door that day. Obviously the incentives
for clinics, hospitals and physicians are to not treat such risky
patients. Any industry actuary can tell you these are the elderly and
the poor and people in high-risk occupations (police, fire, farmers).
So this plan would not just encourage but reward discrimination
against these groups. Now what are the systemic consequences of this?
First the ratings systems become totally skewed, since the "best"
clinics and physicians are not really the best at treating people but
the best at not treating (i.e. avoiding) them. Steering consumers to
such physicians and clinics only sets up a nice negative reinforcing
feedback. Second this shift in the system to primary care physicians
is also misguided. Again it encourages less care for the seriously
ill. Primary care people are fine for treating routine cases but even
the best of them know their limitations and the importance of calling
in an outside expert. By reducing the incentive to do this you risk
mistreatment, which in the long run will cost money. Curiously we
built a model of a typical nursing staffing system that shows just
such results when an anomaly or a high risk patient can throw an
entire floor into what we term a death spiral. Curiously this bizarre
plan reminds me of No Child Left Behind with its emphasis on test
scores. On a moral level on has to ask what is this country coming to?
On an intellectual level one has to ask don't these people understand
how real systems work? In fact don't they even understand statistics?

Amy Wilde (10) (8) (8) (9) (10)

We need to serious
look at how other civilized nations pay for health care. They are more
successful at it than the U.S. Our health reform did not go far
enough. Recent "gouging" by health insurers using the reform bill as
an excuse demonstrates how essential the "public option" was to making
the whole scheme work. The individual mandate penalty is too low to be
very effective. Some type of uniform, "single payer" system will
eventually be needed to make any real headway at cutting
administrative costs.

Connie Morrison (8) (10) (10) (10) (3)

Alan Miller (9) (2) (8) (3) (0)

By getting
lobbyists and insurance companies completely out of health care, where
their commitment is to the bottom line, dollars and profit, we could
join every other civilized nation by offering health care to every
citizen. Health care is a matter of right, not a method for some to
enrich themselves while others go wanting, to the point of death in
some instances. When we choose greed over need, there is something
radically wrong with our priorities.

Chuck Lutz (10) (8) (9) (8) (10)

Vici & Seiki Oshiro (10) (10) (10) (10) (10)

Donald H. Anderson (8) (5) (5) (10) (8)

The biggest
problem is the individual cost of health plans and differences in
getting compatibility of services between the various plans.

William Kuisle (10) (10) (8) (9) (9)

Nancy Jost (-) (-) (-) (-) (-)

SHIP is a great
program that starts too late; it should include early childhood when
many of lifeís trajectories begin. The research through the ACE Study
and many other bodies of research show that if we start in elementary
school in changing behaviors we are starting too late. In rural
Minnesota we have a shortage of dentists and an even greater shortage
of those who will see people on MN health care programs and we had
what we thought was a great, innovative solution to this problem (see
below).

Letter-to-the-EditorOctober 11,
2010

DHS takes away critical program from the very children it seeks to
help.

Recently the Minnesota Department of Human Services (DHS) eliminated a
dental care program that benefited thousands of children in the state.
The Collaborative Oral Health Practice Model was developed so young
children from lower income families could be seen by a highly trained
dental hygienist outside the traditional dentist office setting in
order to meet their Head Start enrollment requirement of having a
dental exam. DHSís reasoning behind eliminating this program? All
children deserve to see a dentist. True, but typically it is very
difficult for children covered by Medical Assistance and Minnesota
Care to find a dentist willing to honor their insurance, this includes
a majority of children enrolled in Head Start.

The Early Childhood Dental Network (ECDN) of west central Minnesota is a
group of over 40 agencies and individuals working to improve
childrenís oral health and access to dental care for low-income
children. The ECDN works with a nonprofit dental clinic to provide
mobile outreach clinics, using this same Collaborative Oral Health
Practice Model, for children in areas where dental care for low-income
families is limited. Dental hygienists went to an environment where
the children were at ease, cleaned the childís teeth, performed an
assessment, connected the most critical cases with the dentist and
educated the rest of the children and parents on the importance of
dental care and seeking an exam. Whether in the classroom or outreach
clinic, this model worked!

The ECDN agrees wholeheartedly with the Stateís rationale that all
children deserve to see a dentist, no matter their familiesí income.
Yet, low reimbursement rates from the State, higher administrative
costs and the multiple barriers faced by some families have
discouraged private dentists from treating our youngest, poorest
children. The result is far fewer children, especially low-income
children, receiving the dental care they so desperately need. The
current dental care system cannot deliver.

This letter is not about the importance of receiving regular oral
health exams by a qualified dentist. Everyone agrees this is
important. This letter is about thousands of children that, because
of the Stateís recent decision, will not have access to ANY form of
dental care. We live in an area of the state where public
transportation is limited, wages are low, families are struggling to
make ends meet, and a visit to the dentistís office is considered a
luxury. Dentists are few, and those who accept Medical Assistance and
Minnesota Care insurances are even fewer. The reality is the
Collaborative Oral Health Practice Model makes sense.

It is time for our residents and communities to react. Commissioner
Cal Ludeman from the Minnesota Department of Human Services and our
local legislators need to hear about the day-to-day challenges that
real families face in finding affordable dental care for their
children. The ECDN understands that times are tough and days are
busy, but please consider sending our state leaders a note to let them
know your support for the Collaborative Oral Health Practice Model, or
any challenges your family may face accessing oral health care in west
central Minnesota.

The Civic Caucusis a non-partisan,
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include persons of varying political persuasions, reflecting years of leadership in politics and
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